- A Note from the Editor
The U.S. Presidential campaign is in full swing, with health care remaining one of the top three issues cited in opinion polls, as structural inequalities among social groups continue to result in unequal rates of health and mortality, and as these inequalities increasingly disfavor middle-income as well as low-income people. This issue of JHCPU is a highway of empirical evidence to a better understanding of just what and where the problems are, marked periodically with signposts to solutions.
Michael Fox, of the University of Kansas, leads off with a Commentary on the subject of consumer-directed health care, a phrase often used to denote plans offered by private insurance companies. Fox argues that the name is “the face of legitimacy” in front of an industry-driven campaign (a) to limit regulatory protections of the consumer, and (b) to encourage the growth of insurance products that place spending options in the hands of the consumer—whether or not those options are truly available, affordable, or even understood. The piece calls into serious question the assumption that marketdriven choices foster consumer empowerment in health care, thus weighing in on one of the many issues dividing the presidential candidates.
Jeanette Ziegenfuss and colleagues from the University of Minnesota studied the American National Election Study data for the presidential elections in 2000 and 2004, seeking to identify changes in health care-related voting behavior. They found that (a) the proportion of people who had trouble getting access to care grew between 2000 and 2004 (from 27% to 35%); (b) a larger proportion of those with difficulties in accessing care voted in 2004 than in 2000; and (c) these people’s preferences shifted to favor the Democratic candidate more heavily in 2004 than in 2000.
In an ethnographic piece, unusual for JHCPU in its tight focus on a representative individual, Emma Tsui gives the reader insight into the circumstances impinging on a low-income African American adolescent’s decisions about sexual concurrency (maintaining more than one temporally overlapping sexual relationship), decisions that have implications for the risk she runs of sexually transmitted diseases. Over an extended series of interviews, Tsui came to appreciate and carefully sketched the extent to which this adolescent’s fundamental concerns about family and livelihood overwhelmed any concern she might have had about her partner’s fidelity. Like other authors in this issue, Tsui concludes that structural factors impinging on the lives of low-income adolescents of color often work much more deeply than choice in shaping behavior. As Tsui writes, “The term sexual concurrency obscures the socially produced configurations of risks and relationships that adolescents face.”
Peter Newman and colleagues from the University of Toronto also argue for the centrality of structural factors in determining whether or not the women participating in the focus groups and key informant interviews they conducted engage in HIV preventive behavior. The women, all with low socioeconomic status and of African or [End Page vii] Caribbean descent, cited the presence of stigma, cultural disconnections, and multiple intersecting forms of discrimination, as well as the disengagement of the Black church, as barriers to HIV preventive behavior. The women saw the Black church and ethnospecific agencies as places where these barriers might be overcome. The authors recommend prevention strategies that focus on structural factors (such as promoting gender equality, economic opportunities, women-controlled prevention techniques, and combating racism in health care) rather than exclusively on individual behavior. (See the articles by Abatemarco et al., Mund et al., Cunningham et al., Peake Andrasik et al., and Horowitz et al. for more work relating to HIV/AIDS.)
Janice Blanchard and colleagues from George Washington University considered whether or not providers are willing to see new patients with hypertension by conducting a simple experiment. Following a script in which the caller reports having been recently released from an emergency room with a diagnosis of hypertension and a recommendation for primary care, the team calculated rates of success in making an appointment with randomly selected providers in Washington, D.C., based on insurance status. (The scenario also included the caveat that the caller could pay no more than...